The Curious Case of China – What Does the COVID-19 Response by China & Asia Pacific Mean for Future Public Health Crises?

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CHAPTERS 

[00:00:00]: China's zero COVID approach: lessons for the world 

[00:05:45]: Reactions to China's reopening: testing requirements on travelers 

[00:08:21]: The real motivation—transparency of data, not public health 

[00:10:09]: When and how should governments lift border restrictions? 

[00:13:56]: Border control as a "safety blanket": why measures persisted too long 

[00:14:51]: Comparing outcomes: zero COVID countries vs. those that opened early 

[00:19:17]: Have we internalized the lessons of COVID-19? 

TRANSCRIPT 

[00:00:02.720] 

Hi, everyone. Welcome to Moving Beyond Pandemic, the podcast from the Migration Policy Institute that looks at how COVID-19 is reshaping all aspects of human movement, from tourism and business travel to labor migration and mobility. I'm Lawrence Huang, Associate Policy Analyst at MPI, and thanks for joining me. Today we're going to look at a region that's close to my heart and that's taken a fairly unique approach to borders during COVID-19, the Asia Pacific. As you might guess from my accent, I'm Australian and I lived through Australia's border closures during 2020 and 21. And as somebody whose extended family is still in China, and I was born in Hong Kong, I was very keen to talk with our guest today, Dr. Karen Grépin, who is Associate professor in the School of Public Health at the University of Hong Kong. She's an expert who researches how governments used travel measures during the COVID-19 pandemic. And she's been doing some really interesting work looking at how this evolved in the Asia Pacific and beyond. We started our conversation with the curious case of China, which kept its borders mostly closed for just about three years, far longer than even the rest of Asia.

[00:01:09.470] 

But at least given the data we have, these restrictions helped to lower case and death rates. You might remember the 2022 Beijing Olympics, where the government allowed thousands of foreign athletes and staff to enter, but imposed such strict quarantine, testing and lockdown requirements that they avoided a big spike in COVID cases. But eventually even China had to open up. And this reopening seems to have led to a spike in COVID related deaths. It also prompted a host of other countries, such as Canada, South Korea, India, Italy to impose new testing requirements on travelers from China. Today, Karen and I discussed China's reopening and these new requirements. We also talk about why governments across the region shut their borders so quickly, so tightly and for so long, whether this made sense in the short term and how they fared in the long run. And we discussed what this might mean for future public health outbreaks in Asia and beyond. Karen Grépin, thank you so much for joining me.

[00:02:08.050] 

Thank you for having me.

[00:02:09.730] 

So you're in a pretty unique position. You both lived through the pandemic in Hong Kong in the travel shutdown, and you're actually an expert studying sort of the border issue. And so with that, here's my first question. China, and to a lesser extent, Hong Kong and East Asia have really carved out their own path on COVID restrictions, sticking to a zero COVID approach for ages and reopening borders far later than virtually all other countries. So in your experience and your research, what lessons does this approach hold for the world going forward?

[00:02:46.610] 

Yeah, I think that's a really interesting question. As you say, Hong Kong and mainland China, as well as a few other places, have pursued a very strict zero COVID regime up until the first 18 months or so of the pandemic. I wouldn't say that the approach was necessarily so different from what we were seeing in other parts of the Asia Pacific region. But in the summer around 2021, we start to see most of the former zero COVID type places, making the decision, a very conscious decision, to move away from this approach. Of course, in order to maintain zero COVID, one must have very, very strict measures at the international border. And so we start to see many of the countries in the region move away for other reasons. Most of them, I would say, are not predominantly public health. Although there were some very legitimate concerns around the fact that many elderly in mainland China, and especially in Hong Kong, were not vaccinated. There was a feeling that they would want to maintain the zero COVID strategy for a longer time period. And that literally meant that we maintained those border control measures for another year, year and a half beyond where the rest of the Asia Pacific moved away from that.

[00:04:09.800] 

So I do think there are some lessons. You know, I definitely think that if we were to now reflect upon even just comparing the former zero COVID places to see which places have done the best when it comes to things like mortality, we definitely see that the places that made a conscious decision and those that had really well developed plans to transition away have kind of won that game in terms of their mortality. We don't have an accurate reflection yet of the true extent of what has happened with regards to mortality in mainland China. But I think it's realistic to assume that the results are not as favorable as they have been in other places, at least from a public health perspective. I think zero COVID and strict border control measures was a really great idea for basically the first 18 months of the pandemic. Then beyond that, it's not clear to what extent it provided any additional health benefit. I think it's also clear that, you know, keeping your borders closed for another 18 months had pretty significant economic and social consequences. And so it's not clear that there was any kind of benefit from those perspective either.

[00:05:18.140] 

Fascinating. And once China did reopen, mainland China opens in early January 2023, we see a whole spate of testing requirements and surveillance measures pop up you know, on travelers coming from China, popping up all across the globe in many different regions. So what do you make of these country specific based on national origin policies so late into the pandemic?

[00:05:43.380] 

Yeah, I have to admit it was quite perplexing as someone who studied these things, to see this most recent round of border control measures being imposed on Chinese travelers. And unfortunate too, because I suddenly was. There was, I think, one day here in Hong Kong where we were not subject to testing requirements coming into Hong Kong. And then literally the next day, we were slapped with a number of measures of testing requirements to leave Hong Kong. So there was like one day where we thought the measures were gone, but then they all came back. You know, what is it they were trying to achieve? If you look at the stated goal of many of these policies, there was a concern that this massive surge of cases that was clearly underway in the mainland, and I think clearly underway going back into early December 2022, this massive surge of cases could potentially lead to the emergence of a new variant that would threaten sort of the stability of pandemic responses globally. However, you know, one that was a theoretical thing. There wasn't actually any evidence, and to my knowledge, there isn't any evidence to suggest that this new variant of concern, meaning one that would supplant the existing streams, has really emerged from China.

[00:07:00.870] 

But also that we know that it's very difficult to control the importation of variants of cases with the particular types of measures that were being imposed. I mean, if anyone had asked or had looked at the literature, we would say that, you know, it was very unlikely that the particular types of measures that were being imposed, you know, some basic testing requirements or something, would do much. And so, you know, my. My general conclusion is I think it's really unrealistic to think that most of these, these current round of measures, some places have renewed them. Canada has renewed them to the end of March into early April, for example, were motivated by public health concerns because it's just not realistic to think that these measures would do all that much.

[00:07:48.110] 

So you used the word perplexing, and I think that that's fascinating and absolutely right. Can I ask what was the case behind putting in these measures? You talked about surveillance and being a variance of concern. Was there perhaps a case for monitoring travelers or there were efforts to test the wastewater on planes or just to randomly test passengers as they arrived to make sure that there weren't variants of concern popping up without hindering travel?

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Yeah, so I think where. I do think there was a genuine concern. And to some extent, what I think many of the countries were trying to do was to try to force mainland China to provide more open and transparent data about what was happening within their borders. What was striking in that rapid shift away from the zero COVID policy in mainland China was how quickly they dismantled their information apparatus. You know, prior to the shift away from zero COVID, China had unbelievable data in terms of where cases were happening, you know, in terms of what, you know, what types of variants were in circulation. You know, because they were running so many nucleic acid tests, they had excellent information on anything they wanted. And in that shift away from zero COVID, they basically stopped testing. And that meant that the data went away. And so I think what a lot of countries were trying to do was they wanted better data, and so they were kind of forcing them. So, you know, but at the same time too, you know, if, if what your concern really was was to ensure that new, no new variants were to come in, or you wanted to know if new variants are coming in from a kind of just basic surveillance type of question.

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The types, again, coming back to the types of measures that were being invoked, I think were actually the wrong ones to do surveillance. And then the other thing we've learned during the pandemic is one can do surveillance in a relatively passive way that doesn't require any disruption to travel. And so if the motivation was about data, one could have done it in a way that was much less disruptive to travel between jurisdictions.

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That makes a lot of sense. You know, part of me sympathizes with policymakers, you know, trying to, trying to develop measures during these crises. And we have so much uncertainty. So there's a question of how can governments determine when and how they lift restrictions? And when all these countries were deciding when they would reopen, what are the key factors that they could have used to make decisions about timelines for reopening and how quickly and what stages?

[00:10:27.600] 

Yeah. So in terms of what we've learned about border control measures, I think there's still a lot of kind of post mortem analysis underway to try to better understand some of these questions. But when it comes to border control measures, I think at the beginning of the pandemic there was an assumption or a belief that border control measures overall were completely ineffective and therefore aren't of much use. At the same time, too, the types of measures that were used in previous infectious disease outbreaks are very different to the ones that countries decided to implement in the context of the COVID-19 pandemic. But what we have learned is that some of those measures actually were quite important and that they probably did lead to relatively important either in terms of delays at the beginning that would have allowed some places to better prepare for what was about to come, or that had some impact in terms of reducing the number of cases imported at the border. But over time, as countries, as populations became increasingly exposed to the virus and I think really importantly became vaccinated, the combination of those two things meant that what was really controlling disease dynamics in local context was really that it was basically the extent to which your population is immune.

[00:11:50.600] 

And so the types of measures, the effectiveness of border control measures actually vary, right? And when it is your population itself that is controlling the, the level of spread or you know, kind of the dynamics around outbreaks in your thing, those border control measures become much less effective and much less important. And that's actually something I think, which is really clear. So some of the places that didn't impose border control measures against China when it reopened and did see large influx of people from those areas didn't experience big surges. And that's because of this kind of population immunity that was built up in those places. And so I think because they are so restrictive, because they have such important economic and social effects, are the benefits really outweighing the costs? And I think once populations are exposed, then that's definitely a time where I think these measures became very out of date. That would be different in the kind of East Asian zero COVID places because they never built up their population immunity. There was an argument to be made to maintain some of these measures for a longer time period. But in the rest of the world where they didn't pursue these kinds of zero COVID approaches, definitely once populations were being exposed to this, there was very little rationale to maintain border control measures that did persist even in many of these places over time.

[00:13:15.950] 

It just, it wasn't producing enough of a reduction in transmission for it to be worthwhile.

[00:13:21.620] 

Right. So that's actually, it's quite a bit earlier in the pandemic for many regions outside of East Asia that were, that had greater population immunity through vaccination, through exposure to the, to the virus in a lot of countries, this was, you know, a year and a bit into the pandemic, and yet that, but, and yet travel measures stayed in place for two and a half years. So outside of the region as well, it's not, it's not just the Asia Pacific that kept these measures in place for a while is tha- that's fair.

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I mean, I was going to say that I think that is quite fair. Throughout the pandemic, I like to refer to border control measures as a country's safety blanket. You know, the sort of blankets that children or babies would have. You know, the safety blanket in that they just felt more comfortable with them than without them. But they didn't really fully understand or appreciate what those border control measures were doing with regards to having much impact at their local disease dynamics. But they just felt better. And because everyone else was kind of doing it and there was a lot of uncertainty, I think that contributed to sort of a persistence of the use of these measures over time when they were probably not doing nearly as much as, as as policymakers think they were, but they were definitely continuing to disrupt international travel.

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I really like that metaphor. And if we can run with that metaphor just a little bit into another question. So there were countries that kept their safety blanket for longer. The, you know, they that China, Australia, Thailand, a bunch of Asia, countries across East Asia and the Asia Pacific generally. And then there were countries that never really had the same reliance on their safety measures on their safety blankets or they lifted them up earlier. You know, I'm thinking about Sweden, for example, and we don't really, from my understanding, have enough data to really assess how they did over the last three years. But with what we know so far, how do you think they've fared over time?

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Do you mean with regards to its overall performance or do you mean with regards to whether or not they were putting in place effective border control measures

[00:15:35.030] 

to their overall performance?

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So that's an interesting question. You know, you've highlighted these areas that kept border control measures in place longer. I mean, the reality is most countries kept something in place for a very long time period, but there were places that had very robust border control measures since early 2020. And these are the countries that I sort of referenced before that were effectively elimination or zero COVID countries. So in those places, they maintain those border control measures until a time where they felt that they had built up enough population immunity through vaccination for them to begin to consider opening up safely. And in some places they actually didn't have much of a choice. It just became so much more difficult to actually do this in the context of either the Delta or the omicron strains, which are so much more transmissible and just so much harder to keep out. If we are to now look at, you know, how did these countries do with regards to cumulative mortality rates? There's no doubt that the countries that pursued that sort of initial elimination or zero COVID strategy have fared the best throughout the pandemic. Right. They, if you look at the Singapores, the New Zealands, to some extent Australia, but definitely Japan, South Korea, they have some of the lowest recorded cumulative mortality rates in the pandemic and an order of magnitude lower than some of the European or North American countries.

[00:17:04.200] 

The countries that kept those border control measures even longer here in Hong Kong, I think is a good example. It's not that they continue to have better health outcomes and if anything, they actually saw worse health outcomes. So to the point after, after the point which the vaccination became widely available, they weren't necessarily any additional health benefits from keeping those measures in place. And if anything, I think this is actually one of the problems that happened in East Asian countries is it provided a kind of level of complacency that actually didn't make vaccination a huge priority. But the countries that did open up, they have done much better than anywhere else in the world. So it's a combination of having kind of this robust elimination strategy which includes border control measures, but it's certainly not all of it, right? You can't have elimination just at the border. Those places, I think when we step back from all this are the ones that we will find probably pursued kind of one of the best approaches. Some of the countries in Asia, which in Europe that never kept some of these border control measures in place, depending on how they, what they worried about domestically, some of them did fine.

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Right. There's a huge range of mortality even amongst countries that sort of didn't pursue border control measures. But a lot of that comes down to the way in which they were able to use other non pharmaceutical interventions domestically until that time that vaccination became widely available.

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Thank you for raising that point. Because I wonder whether that's one of the lessons that we'll learn from the pandemic is that you can't stop this at the border. And it was something you mentioned, right? You need to have interventions that look domestically and at the border and at travel. So looking forward as we wrap up, do you think we've internalized these lessons and do you think the experiences of COVID-19 are going to shape how Hong Kong and China and East Asia react to a similar public health crisis in the future? If we're faced with a similarly unknown highly transmissible pathogen, will these countries shut down again for such a long time?

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I think in general, it's been difficult to internalize all of the lessons from the pandemic across all the spectrum of non-pharmaceutical interventions. It's a lot. There's a big debate right now happening about a recent Cochrane review on the use of face masks for. Right. And this is something that pretty much every country adopted at some point and we still don't have a clear consensus about how effective masks were. And you start thinking about that in the context of border control measures, which are even more complicated and in some ways even harder to study. I think it's not entirely clear what the lessons are. I think there are some consequences of that. I think the belief that we had at the beginning of the pandemic, we being the global community, that travel restrictions have no place because they're never effective, has dramatically changed. I think there's now a realization that under some contexts, and depending on the type of infectious disease that we think we're dealing with, it might be valuable to impose some of these measures. I think that is actually a really important lesson. If a new infectious disease were to come along that something like COVID in terms of its transmissibility, but you know, something like SARS or Ebola with regards to its mortality, we probably would really want to consider the use of widespread use of border control measures to try to, to slow down global transmission.

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But the problem is we don't have a clear framework for that, that kind of thinking yet. And so my concern is that we'll overreact a lot. And so we'll actually start to see many countries imposing border control measures for things that are probably not warranted. Every time we're going to see something pop up, we'll probably see some country impose some form of travel restriction and frequently the kinds of things that don't do all that much but are very disruptive to travel. And so I think, and I'm continuing to work on this, I'm hoping that there will be some ability to condense all this into a way that will help provide guidance to policymakers in the future about what are the conditions under which border control measures make sense and what are the conditions under which they do not. And so that's something that I think hasn't been fully internalized yet, but I hope will continue to be distilled in the coming years.

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Absolutely. And I definitely agree and I'm very much looking forward to seeing where this sort of conversation and research goes. This has been a fascinating discussion. Definitely lots of food for thought as we get used to this quote unquote post COVID normal and new ways of traveling. Thank you so much for your time.

[00:22:09.700] 

Thank you so much for having me today.

[00:22:13.220] 

That was Dr. Karen Grépin From the University of Hong Kong. This conversation reminded me that we haven't really crystallized and internalized the Lessons of COVID-19. As we were talking about China's reopening and the most recent round of testing measures imposed on travelers from China, I was struck that she called this a perplexing decision. This was in January 2023, three years into the pandemic, and yet we still don't have a clear, transparent rationale for when we use border restrictions and travel measures are still around, even if they're less controversial and less restrictive now, as of April, visitors to to the U.S. Still need to be vaccinated. I also really liked Karen's metaphor of the safety blanket. For many of us, especially people who, like me, lived in countries like Australia with the strictest border closures, people genuinely wanted travel restrictions, at least for a while. And to me, this shows that we need to better understand why travel measures became so widespread, why in some countries they stayed for so long, and what this tells us going forward. As Karen said, these decisions aren't just made for public health reasons, and I think we need to get deeper into how governments decide to impose and lift these restrictions.

[00:23:25.950] 

On that note, I'll make a plug for a series of case studies we'll be releasing at MPI looking at this COVID and mobility issue in different regions, including one by myself on the Asia Pacific, which will be available later this year at migrationpolicy.org/Topics/Coronavirus, where you can also find our other work on borders and pandemic preparedness. If you want to hear more, please subscribe to this podcast, Moving Beyond Pandemic wherever you find this podcast or at migrationpolicy.org/podcasts thank you to my colleagues Lisa Dixon, Michelle Mittelstadt, and Yoseph Hamid for producing this podcast. The music you heard on today's episode was Juno and the Space Maze by Loopop. I'm Lawrence Huang. Thanks for listening.